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Difficulty: EasyPreoperative and Postoperative Care

A 65-year-old man is evaluated on postoperative day 6 following an elective open sigmoid colectomy for recurrent diverticulitis. Over the past 24 hours, he has developed a fever and increasing pain at his surgical incision site. His temperature is 38.5°C (101.3°F), blood pressure is 130/80 mm Hg, and pulse is 95/min. Examination of the abdomen reveals intact surgical staples, but there is a 4-cm area of erythema, induration, and warmth around the lower half of the incision. Gentle palpation of this area yields a small amount of purulent discharge. The remainder of his abdominal examination shows mild tenderness without rebound or guarding. Which of the following is the most appropriate next step in management?

  1. Remove the surgical staples and open the affected portion of the incisionAnswer
  2. B
    Administer intravenous vancomycin and piperacillin-tazobactam without opening the wound
  3. C
    Order a computed tomography scan of the abdomen and pelvis with intravenous contrast
  4. D
    Perform a lower extremity venous duplex ultrasound
  5. E
    Reassure the patient that this is a normal physiologic response to the surgical procedure

Answer

Remove the surgical staples and open the affected portion of the incision
The correct answer identifies that the patient has developed a superficial surgical site infection (SSI), which classically presents between postoperative days 5 and 7. The hallmarks of a superficial SSI are localized erythema, induration, warmth, and purulent drainage. The standard of care and most critical initial step in managing a superficial SSI is to obtain adequate source control. This is achieved by removing the staples or sutures over the affected area to open the incision, allowing the purulent material to drain fully. The wound is then typically packed and allowed to heal by secondary intention. Antibiotics are generally reserved for cases involving systemic signs of sepsis, significant surrounding cellulitis, or immunocompromise.

Step-by-Step Solution

1
Analyze the patient's postoperative timeline and vital signs.
The patient has a fever on postoperative day 6.
Timing of postoperative fever provides clues to the etiology (the '5 Ws'). Postoperative days 5 to 7 typically correlate with wound infections ('Wound').
2
Evaluate the physical examination findings.
Erythema, induration, and purulent discharge at the incision site confirm a superficial surgical site infection (SSI).
Purulence is a definitive sign of infection requiring intervention.
3
Determine the most appropriate management for a superficial SSI.
The primary treatment is source control by removing staples/sutures to open the wound and allow it to drain.
Without adequate drainage, the infection will not resolve, even with antibiotic therapy.

Key Concept

The primary management of a superficial surgical site infection (typically occurring on postoperative days 5-7) is source control by opening the incision to allow for purulent drainage.
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Topics

Preoperative and Postoperative Care

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